EAST GEORGIA HMA PHYSICIAN MANAGEMENT, LLC - NPI NUMBER 1487983151

Summary

Provider Name: EAST GEORGIA HMA PHYSICIAN MANAGEMENT, LLC

NPI Number: 1487983151

Clasification: Psychiatry & Neurology (2084N0400X)

Specialization: Neurology

Address:
1497 FAIR RD
STATESBORO, GA
ZIP 30458

Phone Number: (912) 486-1626



Detailed Information

EAST GEORGIA HMA PHYSICIAN MANAGEMENT, LLC is a neurologist in Statesboro, GA. The provider is a Neurologist specializes in the diagnosis and treatment of diseases or impaired function of the brain, spinal cord, peripheral nerves, muscles, autonomic nervous system, and blood vessels that relate to these structures. The assigned NPI number for this provider is 1487983151 and is registered as an organization entity type and is a multi-specialty group.

The provider's business address is:

1497 FAIR RD
STATESBORO, GA
ZIP 30458-822
Phone: (912) 486-1626

The provider's authorized official is Michael L Gingras .
The authorized official title is Vice President and has the following contact phone number (239) 598-3131.

The enumeration date for this NPI number is 12/9/2009 and was last updated on 11/26/2012.

Map - Location of Practice

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Taxonomy Codes

The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1 2084N0400X Psychiatry & Neurology Neurology No
2 207RC0000X Internal Medicine Cardiovascular Disease Yes

Other (Legacy) Identifiers

The following legacy identifiers are available for this provider:

No. Other Provider Identifier Other Provider Identifier Type Other Provider Identifier State Other Provider Identifier Issuer
1 202G703431 MEDICARE PIN GA

NPI Record

No. Field Name Field Value Field Definition 1
1 NPI 1487983151 The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
2 Entity Type Code 2 Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
3 Employer Identification Number EIN The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
4 Provider Organization Name Legal Business Name EAST GEORGIA HMA PHYSICIAN MANAGEMENT, LLC The name of the organization provider. If the provider is an organization, this is the legal business name.
5 Provider First Line Business Practice Location Address 1497 FAIR RD The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
6 Provider Business Practice Location Address City Name STATESBORO The city name in the location address of the provider being identified.
7 Provider Business Practice Location Address State Name GA The State code in the location of the provider being identified.
8 Provider Business Practice Location Address Postal Code 304580822 The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
9 Provider Business Practice Location Address Country Code If outside U S US The country code in the location address of the provider being identified.
10 Provider Business Practice Location Address Telephone Number 9124861626 The telephone number associated with the location address of the provider being identified.
11 Provider Enumeration Date 12/9/2009 The date the provider was assigned a unique identifier (assigned an NPI).
12 Last Update Date 11/26/2012 The date that a record was last updated or changed.
13 Authorized Official Last Name GINGRAS The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
14 Authorized Official First Name MICHAEL The first name of the authorized official.
15 Authorized Official Middle Name L The middle name of the authorized official.
16 Authorized Official Title or Position VICE PRESIDENT The title or position of the authorized official.
17 Authorized Official Telephone Number 2395983131 The 10-position telephone number of the authorized official.
18 Healthcare Provider Taxonomy Code 1 2084N0400X Code designating the provider type, classification, and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1.
19 Healthcare Provider Primary Taxonomy Switch 1 N
20 Healthcare Provider Taxonomy Code 2 207RC0000X
21 Healthcare Provider Primary Taxonomy Switch 2 Y
22 Other Provider Identifier 1 202G703431 Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
23 Other Provider Identifier Type Code 1 08 Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
24 Other Provider Identifier State 1 GA
25 Is Organization Subpart Y
26 Parent Organization LBN HEALTH MANAGEMENT ASSOCIATES, INC
27 Parent Organization TIN
28 Authorized Official Name Prefix Text MR.
29 Healthcare Provider Taxonomy Group 1 193200000X MULTI-SPECIALTY GROUP
30 Healthcare Provider Taxonomy Group 2 193200000X MULTI-SPECIALTY GROUP

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This page was last updated on: 3/10/2015

(1) Field Definition Source-. Federal Register / Vol. 69, No. 15 / Friday, January 23, 2004 / Rules and Regulations - Part II Department of Health and Human Services Office of the Secretary 45 CFR Part 162 HIPAA Administrative Simplification: Standard Unique Health Identifier for Health Care Providers; Final Rule

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